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The NIH VBAC Consensus Conference: Will It Pave the Road to Hell with Good Intentions?

First the good news: based on the presenters, it looks like the NIH VBAC conference will be a great improvement over the elective cesarean surgery travesty of four years ago. The conference seems likely to provide solid, evidence-based information on for whom and under what circumstances VBAC is safest and most likely to end in vaginal birth. Objective, unbiased information on these points is sorely needed, as illustrated by this 2008 response by ACOG vice president Dr. Ralph Hale, who one would expect to know better, to a plea to make VBAC more available:

VBAC is potentially an extremely dangerous procedure for both mother and infant. Although 98% of women can potentially have a successful VBAC, in two percent of cases the result can be a rupture of the old scar. If this happens, then death of the baby is almost certain and death of the mother is probable. Even if the mother does not die, virtually 100% will lose their child bearing ability. To prevent these disasters, the ability to perform immediate surgery is critical.

In point of fact, with appropriate care the scar rupture rate can be 0.5% or less (6,13,15), not 2%, and the chance of the baby dying as a result of scar rupture is 5% (9), not “almost certain.” As for the mother, women rarely die or have hysterectomies, but both are more common with elective repeat cesarean than planned VBAC (3,17,18,19).

Before we break out the champagne, though, consider this: nowhere in the program is any acknowledgement of a patient’s fundamental right to refuse surgery. Quite the opposite. The background statement is rife with the language of doctors giving (or withholding) permission:

For most of the 20th century, once a woman had undergone a cesarean . . ., many clinicians believed that all of her future pregnancies required delivery by cesarean as well. However, in 1980 a National Institutes of Health Consensus Development Conference panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered.

Even more telling, VBAC is positioned as a patient and provider “preference.” The background section uses this term as does the title of the session on obstetric decision making, and Anne Lyerly, the obstetrician speaker on VBAC ethics, is co-author of the commentary “Mode of delivery: toward responsible inclusion of patient preferences.”

The problem with patient preference is that it is readily trumped by provider preference. If VBAC is no more than a menu option, the danger in determining who makes a good candidate and what constitutes optimal circumstances for VBAC is that it legitimizes its opposite: doctors and institutions denying VBAC to women they don’t think make the cut or where they don’t think safety for VBAC is adequate. (The latter, BTW, is spurious. Emergencies occur in non VBAC labors. If a hospital isn’t safe for a VBAC labor, then it isn’t safe for any woman to labor there. Not to mention that ACOG guidelines for labor induction and American Society of Anesthesiologist guidelines for epidurals require the ability to perform an urgent cesarean because of the potential for just such emergencies, but no one is setting strictures on these procedures [1,2].)

A secondary danger of the “preference” perspective is that conference presenters may treat non-clinical factors such as “medico-legal concerns” and “economic considerations” as valid reasons for VBAC refusal instead of obstacles that must be overcome. This would leave us where we are now with obstetricians and hospitals free to do as they choose, and what they choose is no VBACs. A 2005 survey found that more than half the women wanting a VBAC were denied that option, a 2009 survey of 2850 hospitals revealed that half of them had a ban or de facto ban against VBAC, and Lord knows we do not need any more stories like Joy Szabo’s.

To give the conference planners and presenters their due, normally, it makes perfect sense to limit procedures to those with the skill to perform them and require their performance in environments with adequate resources. It makes sense as well as to allow providers and institutions to decline performing them. But VBAC is the exception because it is not a procedure. Labor is what inevitably happens at the end of pregnancy. Refusing VBAC means forcing women to agree to major surgery they neither want nor need in order to obtain medical care.

Depriving a woman of choice on grounds of the baby’s safety, the primary clinical rationale for VBAC denial, values the child over the mother. This is not hyperbole. According to studies of a large U.S. population, the maternal risk of death (3 per 10,000) with elective repeat cesarean is in the same ballpark with the risk of the baby dying subsequent to scar rupture during a VBAC labor (1 per 10,000) (13,19). Moreover, as the conference will discuss, a woman undergoing repeat cesarean not only runs the risks of that surgery, but an increasing risk of placental attachment abnormalities in any future pregnancies as she accumulates surgeries, abnormalities that threaten both her life and that of the fetus. By contrast, once a woman has a VBAC, she will almost always continue to have uneventful VBACs in future pregnancies. VBAC denial is the sole instance where doctors feel justified in compelling one person to undergo a medical procedure to benefit another party, but no ethical principle or law allows this, including when the beneficiary will otherwise surely die, which is far from the case with VBAC.

Failure to recognize that VBAC is a right has another consequence as well. If you start from this premise, it follows that a key question will be how best to promote safe vaginal birth in women desiring VBAC, but this is missing from the agenda. My researches for the VBAC chapter of the new edition of Obstetric Myths turned up much food for thought on this issue. For example, a study on the large U.S. population mentioned above reported scar rupture rates of 9 per 1000 with labor augmentation and 10 per 1000 with induction but only 4 per 1000 in women laboring spontaneously (13). If every woman had labored without stimulation, 63 women would have had scar ruptures instead of 124. On the other hand, a study reported equally low scar rupture rates in induced labors (3 per 1000) as in labors with spontaneous onset (16), which suggests that while spontaneous labor is optimal, women who truly require induction can be induced without excess risk provided clinicians pay proper attention to patient selection and induction protocol. Research also shows that physiologic care substantially increases VBAC rate and reduces scar rupture rate (15). The birth center VBAC study reported a VBAC rate of 81% in women with no prior vaginal birth, 9 to 20 more women per 100 than among similar women in nine studies (4,5,7,8,10-12,14,20) who had conventional obstetric management. The scar rupture rate overall was a mere 2 per 1000.

We rightly should applaud any effort that helps women and clinicians decide between planned VBAC or repeat cesarean but lament any attempt to curtail a woman’s right to refuse surgery, be it on clinical or nonclinical grounds. VBAC is a right, not a preference, a right, let me add, not abrogated by the clinician’s opinion of its wisdom. It does not matter if you, me, and everyone on the planet were to line up and say to a woman VBAC is a bad idea in your case, she still has the right to say “no” to surgery. Clinicians and institutions must be brought to accept their ethical and professional obligation to provide best practice care to every woman wanting planned VBAC. If the conference fails in this task, then whatever it accomplishes, it will fall short of its duty to childbearing women with previous cesareans.

I was not given any information in regards to cesaerean. I signed a VBAC Consent form that stated that I could die, the baby could die, the baby could end up with a neuralogical problem, I could end up losing my uterus etc and so forth if I attempt to VBAC. I had to sign it line by line and sign again at the bottom. I did not see and have yet to ever see such a document outlining the dire consequences of Cesarean. The Cesarean I had, I signed a surgery consent with the word cesarean section written at the top.

One of our local hospital systems offers what they call a “TOLAC” consent form (Trial of labor after cesarean). It is one sheet, and it actually goes through both risks and benefits of cesarean and vbac delivery. It is fairly balanced sheet. But it’s only part of the battle.

A mom I know had been going to an OB for six months during her pregnancy, and he was aware she wanted a VBAC after multiple cesareans. She had studies in hand and had discussed it. He agreed but had reservations. Two weeks before her EDD, he called her to a meeting (or more accurately stated, an attempted ambush)with the hospital CoS and Chief Res of OB – an attorney was supposed to be there too but wasn’t. She called me in to help her advocate for herself. The attempts to manipulate this woman were from every angle – how her uterus was going to blow up like a bomb, etc., etc. In there thorough but narrowly informed discussion, they did not once mention the risks of a repeat cesarean until I brought it up, and their response was to brush it off with statements like, “well, I’ve never *seen* a mother die from a cesarean” and “I’d rather have a woman hooked up to a colostomy bag from a bowel injury with a scalpel than have a child with a disability.” – those comments were from the resident OB. He totally blew off the risks of an elective cesarean, and was completely indignant that I’d even had the gall to ask about it. He was perfectly willing to cite one shoddy study and refute any better ones to prevent her from going through with a VBAC, but treated the risks of ERCS as if it was as simple as having her blow her nose.

Another experience I had was when planning my own VBAC. For the first part of my pregnancy, I saw an OBGYN practice who said they were pretty open to VBAC; but every time I went in, someone had to mention all the risks I would be facing. Now, I could deal with this to a point, because I do think it’s important for women to consider this to make an informed decision; but after hearing about it ad nauseum for several months, I finally asked the OB in the practice point blank, “So, would you be hammering all the risks of surgery in my head if I were just planning a cesarean?”, and her response was also point blank, “No” (and an admission that liability influenced this.) Had I continued with this practice, I would have signed the same TOLAC form as mentioned above, but even though I was an ideal VBAC candidate (and also NOT an ideal candidate for elective major surgery), my visits were heavily weighted with unnecessary bias.

So, having a standard form doesn’t mean a woman is getting the fair shake of information. All we women are asking for is balanced information, and some docs are willing to give that, but many are not.

(Hmm, the NIH conference is discussing how to present risks to women right now. Very interesting stuff.)

You haven’t answered my question to you. Would you have proceeded with a VBAC attempt if it would have voided your health insurance and left you responsible not only for the costs of the VBAC, but for all healthcare costs for your family forever?

I assume you have avoided answering because you know that you might have felt compelled to have a repeat C-section because you cannot afford to lose your health insurance. In that case, you should be able to understand the position of most obstetricians.

It amazes me that VBAC activists are so fixated on blaming obstetricians for everything that they can’t see the obvious: in this situation obstetricians are their allies.

If the insurance company refuses to cover the chemo your doctor recommends, do you blame the oncologist? If the insurance company refuses to cover your diabetes meds, insisting that your diabetes is a pre-existing condition, do you blame your internist?

The only reason to blame obstetricians would be if you refused to see the situation clearly and used VBAC as yet another opportunity to foster resentment of doctors. In other words, the only reason to do so would be if you were more interested in being angry than in changing the current policy.

Um, there is a HUGE difference between MY health insurance not covering something and the doctor’s malpractice insurace not covering something.

In the first instance I, the patient, have to make less than optimal choices based on my own financial constraints. (And I also may have a way to argue with the insurance company, either by filing a complaint or through my employer, or by filing a lawsuit to require coverage, etc.)

In the second instance you, as a professional, are alowing your own personal financial considerations to affect the quality of care you provide to your patients. It has nothing to do with the patient’s health or your medical opinion, it’s your own personal financial interest. That is a classic example of what we lawyers call a conflict of interest. You are in a position where what is best for your patient conflicts with what is best for you. I’m no doctor, so I don’t know what medical ethics has to say about that situation, but I doubt it’s “convince the patient that what’s best for you is really what’s best for them too even if medically it’s not.”

I feel for individual practitioners who find themselves between a rock and a hard place, and who are honest with their patients about the situation, but OBs as a profession have not done this. Maybe Dr. Amy is the exception, but as a group, and led by ACOG, OBs have chosen to lie to, manipulate, and actively disempower their patients. That is not something that an ally does. If the real problem is that malpractice insurance will not cover VBAC even though it is in fact safer for most women, then ACOG should stand up and say so, and present the evidence to the insurers. The fact that it doesn’t leads those outside the profession to suspect that personal financial interest in performing surgeries has clouded the vision of OBs as a professional group and that they do not have our interests at heart.

In many states a doctor cannot practice without malpractice insurance, so we’re talking about giving up the profession. Moreover, even if the doctor is allowed to practice, no doctor could possibly afford a $10 million judgment.

VBAC activists are making a terrible mistake in ignoring the fact that doctors are their allies in this fight. You may enjoy railing against “evil” doctors but that merely demonstrates that you don’t understand the problem.

Amy, whatever you may be, you sure as hell don’t sound like an ally. What are you doing to advocate for malpractice coverage not to discriminate against VBAC? Can you provide links to organizations of OBs working to change that aspect of malpractice coverage? (No, general tort reform doesn’t count). Can you provide websites where OBs discuss how the system is forcing them to choose between appropriate patient care and their own pocketbooks? Can you provide press releases where a group of OBs tries to raise awareness of the problem and that malpractice insurers are putting women and babies’ safety at risk? ‘Cause if you can, maybe I’ll believe you’re an ally.

If OBs are working to change the VBAC bans and the ACOG statement, please let me know who is doing this and where, because I would most happily support them. However, until I see that the major lobbying group for the industry is considering making actual changes in their stance, I’m not sure how truthful your statement is. If doctors want to provide VBACs, they very well can and they can work towards changing the standard of care. Certainly OBs continue to use cytotec/miso off-label and against the manufacturer’s own advice, so why would “allowing” the natural end of a pregnancy to take place be terribly different?

“VBAC activists are making a terrible mistake in ignoring the fact that doctors are their allies in this fight. You may enjoy railing against “evil” doctors but that merely demonstrates that you don’t understand the problem.”

1) It is very difficult to empathize with the medical community when women are being lied to about the reasons they are being cut. Plain and simply, as is in any doctor-patient relationship, women should know all the reasons are that her provider is making a recommendation; I would be far more empathetic if more providers were up front about that.

2) Personally, I have actually asked providers in my community – what can we, the moms, the consumers do to help you serve us better, and the answer I have gotten from those I’ve spoken with is “I don’t know.” I don’t feel it’s productive to vindicate an entire profession, but how many providers are actually working on improving this? The handful that actually are, are virtually rockstars in the VBAC advocacy community. But there are maybe three of them. We are itching to find people who actually have power and influence, and are willing to put themselves out there to find the solution.

“It is very difficult to empathize with the medical community when women are being lied to about the reasons they are being cut.”

Nobody is asking you to empathize, merely to recognize reality. I know you’d prefer to think that obstetricians are depriving women of VBACs, but I practiced back when the VBAC rate was quite high; the standard was to offer every eligible woman a VBAC and most of us did. Obstetricians were upset over the ACOG guidelines, and even more upset over the actions of malpractice insurers.

For those who are looking for proof of my contention, you need look no further than the NIH conference. Why do you think there is a conference in the first place? It’s because doctors want to do VBACs. Did you listen to the speakers? Virtually every single one said there should be more VBACs; no one defended the status quo.

VBAC activists need to look beyond the juvenile tactics of resentment and address reality. At this point, most VBAC activists don’t appear to have a clue as to the real issues.

I suspect that tomorrow the doctors are going to issue a statement that calls for a liberal VBAC policy, dropping the requirement for in house anesthesia and dropping the requirement that an obstetrician be present at all times. And I further suspect that it is going to be meaningless unless malpractice insurers can be brought on board. They don’t want to lose money.

VBACs WILL result in preventable neonatal deaths and women sue and win despite the fact that they signed consents acknowledging the risks. Unless malpractice insurers are prohibited from dropping coverage for VBACs, nothing will change.

In response to your comment #42 (I hope this links to it) as well as other comments, you made frequent references to OBs who want to do VBACs, and blamed the mean ol’ malpractice insurance companies for the OBs’ refusal to attend VBACs. I understand the problem — sure, there are a lot of OBs who want to do VBACs, but can’t because of malpractice insurance; and we need tort reform. We agree on that. *However*, the huge swing against VBACs did not happen primarily in response to the lawsuits, but in response to ACOG’s change of recommendation that VBACs only be attempted with an on-site anes. & OB, which put VBACs out of reach for probably most women, except for those with access to large hospitals, and/or those willing to risk “going against” ACOG’s guidelines. [I don’t even need to say “correct me if I’m wrong,” because I know you will.] So, it seems to me that ACOG — who are obstetricians, not malpractice insurance providers — sort of made at least some of this mess, by changing the “standard of care” from VBACs being attempted with a doctor readily available, to being “immediately” available. With the change in wording, that left any OB who wanted to attend VBACs hung out to dry. While lawyers undoubtedly used the change in guidelines to their advantage, it seems that the thrust of the anti-VBAC pendulum swing happened due to obstetricians themselves, in the form of ACOG’s recommendations.

You’re probably going to argue that “any dead/injured baby is indefensible,” and that may be true to some extent; however I know enough to know that there is also a term along the lines of “community standard of care,” which basically is “but, mom, everybody else is doing it!” If doctors can’t look around and see all their other colleagues doing something, they’ll have an awfully hard time defending their actions (or inactions) in court, even if they were reasonable at the time.

In your comment, you continue to drift off the real point. VBAC leads to preventable neonatal deaths, women sue if their babies die, juries pay out, and malpractice insurers do not want to cover the risk. That is the fundamental issue and NOTHING will change unless that issue is addressed.
Tort reform would. It has in Mississippi — our state was notorious for high malpractice payouts — so much so that several years ago many doctors were leaving the state for “greener pastures,” because the malpractice insurance was too high. When the law changed and malpractice insurance companies knew that their damages would be legally limited, they could afford to drop their rates. Change the risk the insurers have, and you change everything. And that goes back to my point, which is actually on point (even on your point), rather than off the point.

There is somewhat of an entitlement mentality, as well as a litigious nature, in our country. There is a huge emotional draw that a bereaved parent or an injured child has on a jury. It leads to many settlements and/or huge payouts even when the doctor has done nothing wrong. I think you and I agree almost totally on this point (I even wrote about it here back in 2008). What to do? Sure, change society — but it’s easier to change laws than to change mentality!

“but in response to ACOG’s change of recommendation that VBACs only be attempted with an on-site anes. & OB”

And that was a very misguided attempt to protect doctors from lawsuits. ACOG likes to point out that obstetricians who follow ACOG guidelines never lose a lawsuit. Obstetricians were being sued by women who consented to VBAC but claimed they didn’t understand the risks. and some of those suits paid out massive judgments. ACOG appeared to think (erroneously, in hindsight) that by promulgating strict guidelines, they could protect obstetricians from lawsuits. Unfortunately, the guidelines were so strict that most obstetricians could not comply with them. Even more unfortunately, the malpractice insurers used this as an opportunity to withdraw ANY coverage for VBAC.

I know that you really, really, really want to ascribe this to an evil plot on the part of obstetricians. However, the proximate cause was successful lawsuits by women who suffered ruptures and claimed they didn’t “understand” that this could happen. Had those lawsuits been unsuccessful, there would not have been any need for guidelines in the first place.

I’m not claiming that obstetricians are wonderful people, or that they are always right. I’m merely pointing out that in THIS instance, obstetricians and patients are on the same side, and the major constraint comes from insurance companies.

Obstetricians are want to do more VBACs. Patients want access to VBACs. Does it make any sense for VBAC activists to insist on blaming obstetricians when obstetricians already agree? How does that contribute toward offering more VBACs? What does it accomplish beyond stirring up resentment? I can assure you that it won’t bring us even a millimeter closer to the goal that we both share.

>> If doctors want to provide VBACs, they very well can and they can work towards changing the standard of care.

Here’s the sad truth. Doctors are not very politically active. We get up very early in the morning, work all day, and come home late at night. Most docs are so tired just doing their job that the idea of political activism is not on the radar. Most if not all OBs are behind expanded VBAC rights, but most are not interested in political activism. We love to grouse, but few like to really act.

RJ–“It is very difficult to empathize with the medical community when women are being lied to about the reasons they are being cut.”

Amy–Nobody is asking you to empathize, merely to recognize reality.

RJ, you just got Amy Tuteur to admit that doctors lying to women about reasons for unnecessary surgery is REALITY. Really, it’s not that big of deal for her to say it, as we need to hear it from someone with some clout and hopefully, like Amy suspects, the NIH conference panel will come back with a favorable consensus statement.

By the way, how sweet that Tuteur believes that a bunch of obstetricians, so passionate about advocating for their patients and so desperate for their patients to VBAC, got together and convinced the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Office of Medical Applications of Research of the NIH to schedule a conference. Obstetrics has historically preserved the status quo even in the face of glaring evidence that they were harming patients, with significant changes being made by mobilized groups of fed up consumers.

Some were offended then and took it personally as a slap in the face against the care they provided. Some are going to take it personally this time around, too.

Of course, Tuteur has ZERO evidence that obstetricians are clamoring to attend VBACs. She’s here to argue a contrary point as usual and to claim that whatever advocacy group she’s interacting with is fringe/marginalized, childish, backward, ill-informed or mentally inferior so that people will fight with her.

Why do you and Nicholas continually speak on behalf of obstetricians like spokespersons? Do you really think you are representative of all OBs? Amy, you haven’t practiced in years and when you did, you had a low cesarean rate from what I’ve read. Nicholas, you say you have a really low cesarean rate. Why is it so hard to admit that so, so many of your colleagues (or past colleagues) are behaving ridiculously?

And doctors being too tired to be politically active? Can you provide evidence beyond your own opinion that this is true? Doctors are always publishing stuff. How can I tell you nicely that “too tired to care” sounds absurd?

“RJ, you just got Amy Tuteur to admit that doctors lying to women about reasons for unnecessary surgery is REALITY.”

Go back and read it again. I specifically said that the accusations about doctors are NOT reality.

How do you expect to be taken seriously when you can’t even be bothered to actually read what is written?

You are proving my point for me. You are so wedded to your sanctimonious resentment that you cannot see what is right in front of you. Clearly you rather indulge your penchant for self unmerited self righteousness rather than find a solution to the problem.

And you’re proving my point that you just like to troll around and bash people you consider to be advocates of some sort. I forgot “How do you expect people to take you seriously?” as a classic line of yours. It’s the same on every site regardless of the topic. What a joke.

And how do you expect your generalizations to be taken seriously without a shred of evidence that obstetricians have been devastated over VBAC bans? At least Nicholas says it’s because they’re too tired for any political activism.

Amy Tuteur, MD :
“RJ, you just got Amy Tuteur to admit that doctors lying to women about reasons for unnecessary surgery is REALITY.”
Go back and read it again. I specifically said that the accusations about doctors are NOT reality.
How do you expect to be taken seriously when you can’t even be bothered to actually read what is written?
You are proving my point for me. You are so wedded to your sanctimonious resentment that you cannot see what is right in front of you. Clearly you rather indulge your penchant for self unmerited self righteousness rather than find a solution to the problem.

And what you have just read above is the Amy Tuteur version of “I know you are, but what am I.”

Drat, I was half an inch away from thinking that underneath the BS, we were actually having a semi-productive conversation. What a shame. My favorite line is the one about indulging in unmerited self-righteousness. That made me laugh out loud. Pot/kettle, anyone?

@Amy Tuteur, MDI know that you really, really, really want to ascribe this to an evil plot on the part of obstetricians.
No, not really (much less “really, really, really”).

However, the proximate cause was successful lawsuits by women who suffered ruptures and claimed they didn’t “understand” that this could happen. Had those lawsuits been unsuccessful, there would not have been any need for guidelines in the first place.
I agree, and this makes things much worse for all of us, because it 1) gives doctors the idea that they have the power/authority to do things that we women have said we don’t want (or not do things that we do want) out of fear of lawsuit [even forcing/coercing women into prenatal screening they don’t want and/or attempting to coerce abortion for “defective” babies, out of fear that somebody will sue them after they have a baby with Down’s Syndrome, that “had they just known” they would have had an abortion — I think the term is “wrongful life”] and 2) it plays up the “pregnant woman is frail, stupid, and unable to really understand things that we men-folk understand,” which leads to all sorts of patronizing, paternalistic attitudes on the part of medical people when it comes to pregnant women.

I’m merely pointing out that in THIS instance, obstetricians and patients are on the same side, and the major constraint comes from insurance companies.
I agree… to a certain extent. I don’t like the stories I’ve heard of OBs, nurses, etc., lying to women — for instance, telling them that it is “illegal” for the women to have a vaginal birth since they’ve had a C-section, and other coercive or downright false statements designed to make them “choose” a C-section. And this goes back to the paternalistic attitude that is augmented by women who were properly informed and consented to a VBAC and later sued claiming they didn’t understand (which I think is completely wrong, but I wasn’t on the jury). It then forces doctors to force/coerce women into doing what doctors won’t get sued for (a C-section) rather than risk being the one in a thousand who will have a uterine rupture — they pull out all the stops to try to keep women from VBACing, for the doctors’ self-protection. We agree that that happens, and I understand why it does, and it’s understandable. But it’s still wrong. W-R-O-N-G, wrong! I’d much rather see doctors tell women the truth — “my malpractice insurance won’t cover me if I allow you to VBAC,” or “there is a 1/1000 chance your baby could die from a uterine rupture, and I don’t want to take the chance that you’ll sue me afterward, so I will not attend you if you VBAC.” But as long as doctors lie to patients and/or give them false or inflated vague statistics about their risk [“you and your baby could DIE if you try a VBAC,” — which is true, but without telling them the actual level of risk, women can’t make a true decision — it’s much like saying, “I can’t let you walk across a street because you could get hit by a car and die,” — again, true, but what is the actual risk?], then we who are being lied to and/or misled have the right to be mad about being lied to and/or misled.

And this does have a bearing on this topic — you say women want to have VBACs and doctors want to attend VBACs. Well, if women and doctors both get riled up enough to actually do something about it, then maybe change will happen. So, while it is antagonistic for women to gripe and complain about the mean doctors that won’t let them attempt a VBAC, it also increases the voice of us “dissidents” who want VBAC to be an option that is kept open. Without us making some noise (like Joy Szabo did going public with her VBAC story, and women in the 50s did with their barbaric treatment in hospitals), most people won’t even know that it is an issue. There is a power to being in a group, rather than thinking that you’re the only one. Maybe this “antagonism” that you’re decrying has been a significant factor in this NIH VBAC Conference, which will change the standard of care to one legally defensible but also more liberal with VBACs. While I would prefer to join forces where possible, if doctors are going to stick their head in the sand (which incidentally, makes their hind-quarters prime targets for a swift kick in the rump), rather than work on increasing VBAC availability for women who want it, then there is going to be antagonism. Especially if women are not told that the real reason they can’t/won’t attend a VBAC has to do with malpractice insurance.

@Nicholas FogelsonWe love to grouse, but few like to really act.
Ain’t that the truth? — for the whole world, not just doctors. But it’s something that needs to be done. Just as you were willing to put your life on hold and spend incredible amounts of money to become a doctor for the future benefits, even so political action can have a bigger payoff than the time and money you put into it. Delayed gratification… a somewhat foreign concept in our microwave instant-access generation. Sigh…

As I predicted, the conference members favor a more liberal VBAC policy, recommended that ACOG revise its guidelines by ending requirement for in house anesthesia and in house obstetrician, and recommend that policy makers address the medico-legal constraints on VBAC.

“So, while it is antagonistic for women to gripe and complain about the mean doctors that won’t let them attempt a VBAC, it also increases the voice of us “dissidents” who want VBAC to be an option that is kept open.”

Do you think that anyone is taking you seriously? You could practically hear the eye rolling by the NIH panel when VBAC activists paraded their self pitying, hyperbolic prattle. VBAC activists were undoubtedly preening before their own constituency, but they were not taken seriously by anyone else.

This example was kind of sad because it appears that Tuteur might actually want women to have the right to VBAC. But she has to assume a contrary role, so you’ll never actually hear it. You’ll hear that VBAC is not a right and “VBAC Activists” are too stupid to understand what’s really going on.

She’s not actually talking about VBAC Activists. She’s talking to the VBAC Activist that she’s invented and that lives in her head. She lives there with the Anti-Circumcision Activist, Natural Birth Advocate, Home Birth Advocate, Anti-Hamas Activist and Alternative Medicine Activist. In her head, every activist is a Rich, White American, but not to worry; Tuteur has already prepared arguments to deal with “these type of people.”

But she’s not actually listening to anyone she interacts with. She’s already pegged you as an activist or advocate and she’s got a fight for you, ready to let you know that nobody takes activists seriously.

They took Tuteur really seriously on Science Based Medicine.

So, no, RJ, from everything I’ve read, you will never have a productive conversation with Tuteur.

Fogelson is really doing the same thing. He engages and listens but he has a similar goal. He speaks on behalf of all OB-GYNs and is trying to convince everyone that they’re really just a bunch of nice people. He wants you all to not be so hard on them. The idea is that, “I don’t do that and nobody I know does that and so if we’re all doing great, then the problem must be with the women or the critics.”

The VBAC friendly doctors you mentioned, RJ, don’t just get rock star status because they attend VBACs. It’s because they recognize the crisis in obstetrics and medicine in general and don’t deny it. They have the wherewithal to speak out against the abuses of their colleagues instead of trolling around with a bullhorn announcing, “Move on, nothing to see here, just some crazy women who have a problem with us nice, smart, well-trained people. Their fault.”

Regardless, the pendulum will swing back as a result of external forces like the NIH conference, consumer groups, public health officials, et cetera, stepping in to shake change into obstetric practice. As a result, practice standards will see a begrudged change and consumer health insurance providers will follow suit. As always, change will not occur from within medical culture because, as seen on this page, some doctors just want you to believe that there really is no problem with the system, just difficult patients.

I strongly agree with nearly everything you’ve said here, but have a small quibble with your statement: “This would leave us where we are now with obstetricians and hospitals free to do as they choose, and what they choose is no VBACs.”

As a certified nurse-midwife who does VBACs (with OB backup), I would love to be able to offer VBACs to everyone who wants one. I am sure there are hospitals and obstetricians who have used excuses about VBAC danger to support their desire not to offer VBACs. However, I personally know a number of obstetricians who wanted to continue to offer VBAC, believing in its relative safety, but were forced to discontinue this option for their patients due to the hospital not allowing it (the doctor would lose his/her privileges if s/he did not conform to hospital protocols), or because the increased insurance premiums charged for continuing to offer VBACs make it financially impossible to continue. The increase was $60,000 in the case of one OB I know. We discussed whether she could continue offering VBACs “under the radar” by advising women to stay at home in labor as long as possible (not very responsible advice) and then refuse c-section when they came in to the hospital, thus forcing the OB to deliver the baby vaginally. The OB told me the insurance company had advised her that if she had too many “accidental” VBACs, her coverage would be terminated.

I believe there are many OBs who, if they were truly free to do as they chose, would gladly offer VBACs. But with the current constraints placed upon them, requiring them to be continually present in the hospital for the duration of a VBAC labor, it becomes increasingly difficult to maintain a professional practice or have a personal life.

If VBAC is to remain a viable option for women, which it should, I believe that one of two things must happen:

1. The restrictions on low-risk VBAC labors must be revised to allow low-risk women (eg, spontaneous onset of labor, no augmentation, non-repeating cause for 1st c-section, history of prior vaginal birth, etc.)to labor without requiring the continual physical presence of the physician.

OR

2. Hospitals offering maternity care will provide laborists, obstetricians employed by the hospital to be immediately available for emergencies 24/7. This will allow obstetricians to be released from the requirement to remain physically present in the hospital during a VBAC labor.

While it’s easy to blame the doctors, and I have done my share of that in the past, I have many physician colleagues who are dismayed over the difficulty in offering VBACs. As the primary care provider for VBAC clients, I must remain in the hospital the entire time that a woman is in labor, just as the OB does. When I was doing only 25 births a year as a midwife, it didn’t seem so bad to have several VBACs whose labors might last 18 hours or more. Now that I do upwards of 150 deliveries a year, plus work full time hours in a clinic, having to spend 18 hours in the hospital is more painful. No matter my love for my clients, my belief in VBAC, and my support of women’s rights (and I do believe it is a woman’s right to choose how she gives birth), I am human and I get tired. When I have not slept because I’ve been at the hospital for 48 hours straight (our normal call rotation in my practice) and I know I have to go in for a full day in the office an hour after I get off call, the flesh is weak and the temptation to decide c-section is a better choice is strong. When a practice supports VBAC, it attracts more than its share of women who want VBAC, placing additional time burdens on the providers. Unless we can develop better protocols for VBAC labors, the risk is that providers will simply burn out and not be able or willing to offer VBAC support any more.

This is just one small piece of the multi-faceted problem our country has made out of VBAC rights, but I believe it is a hugely important factor in making VBAC readily available to women, and should not be overlooked.

“Consumers will always be taken seriously. They’re where the money is.”

Yeah, that explains why doctors are so nice to patients.

You’re joking, right? The money comes from health insurance companies, and health insurance companies are paid by employers. Consumers are very low on the totem pole when considering “where the money is.”

Do you think that anyone is taking you seriously? You could practically hear the eye rolling by the NIH panel when VBAC activists paraded their self pitying, hyperbolic prattle. VBAC activists were undoubtedly preening before their own constituency, but they were not taken seriously by anyone else.

Didn’t watch the conference, so can’t say yea or nay. However, Joy Szabo did get national attention with her making her struggle to get a VBAC public. Perhaps that single event, any other single event, or even all these events taken together, didn’t change anybody’s mind. But then again, maybe they did. Why put pressure on anybody if pressure doesn’t change minds?

The money comes from health insurance companies, and health insurance companies are paid by employers. Consumers are very low on the totem pole when considering “where the money is.”
This is sadly true, which is why the current health system is bad and the proposed changes in Congress (if anybody even really knows what they are), probably won’t help and may make things worse. Money talks, but the more steps there are between payer and consumer, the less financial accountability there is.

Birth Sense :I strongly agree with nearly everything you’ve said here, but have a small quibble with your statement: “This would leave us where we are now with obstetricians and hospitals free to do as they choose, and what they choose is no VBACs.”
As a certified nurse-midwife who does VBACs (with OB backup), I would love to be able to offer VBACs to everyone who wants one. I am sure there are hospitals and obstetricians who have used excuses about VBAC danger to support their desire not to offer VBACs. However, I personally know a number of obstetricians who wanted to continue to offer VBAC, believing in its relative safety, but were forced to discontinue this option for their patients due to the hospital not allowing it (the doctor would lose his/her privileges if s/he did not conform to hospital protocols), or because the increased insurance premiums charged for continuing to offer VBACs make it financially impossible to continue. The increase was $60,000 in the case of one OB I know. We discussed whether she could continue offering VBACs “under the radar” by advising women to stay at home in labor as long as possible (not very responsible advice) and then refuse c-section when they came in to the hospital, thus forcing the OB to deliver the baby vaginally. The OB told me the insurance company had advised her that if she had too many “accidental” VBACs, her coverage would be terminated.
I believe there are many OBs who, if they were truly free to do as they chose, would gladly offer VBACs. But with the current constraints placed upon them, requiring them to be continually present in the hospital for the duration of a VBAC labor, it becomes increasingly difficult to maintain a professional practice or have a personal life.
If VBAC is to remain a viable option for women, which it should, I believe that one of two things must happen:
1. The restrictions on low-risk VBAC labors must be revised to allow low-risk women (eg, spontaneous onset of labor, no augmentation, non-repeating cause for 1st c-section, history of prior vaginal birth, etc.)to labor without requiring the continual physical presence of the physician.
OR
2. Hospitals offering maternity care will provide laborists, obstetricians employed by the hospital to be immediately available for emergencies 24/7. This will allow obstetricians to be released from the requirement to remain physically present in the hospital during a VBAC labor.
While it’s easy to blame the doctors, and I have done my share of that in the past, I have many physician colleagues who are dismayed over the difficulty in offering VBACs. As the primary care provider for VBAC clients, I must remain in the hospital the entire time that a woman is in labor, just as the OB does. When I was doing only 25 births a year as a midwife, it didn’t seem so bad to have several VBACs whose labors might last 18 hours or more. Now that I do upwards of 150 deliveries a year, plus work full time hours in a clinic, having to spend 18 hours in the hospital is more painful. No matter my love for my clients, my belief in VBAC, and my support of women’s rights (and I do believe it is a woman’s right to choose how she gives birth), I am human and I get tired. When I have not slept because I’ve been at the hospital for 48 hours straight (our normal call rotation in my practice) and I know I have to go in for a full day in the office an hour after I get off call, the flesh is weak and the temptation to decide c-section is a better choice is strong. When a practice supports VBAC, it attracts more than its share of women who want VBAC, placing additional time burdens on the providers. Unless we can develop better protocols for VBAC labors, the risk is that providers will simply burn out and not be able or willing to offer VBAC support any more.
This is just one small piece of the multi-faceted problem our country has made out of VBAC rights, but I believe it is a hugely important factor in making VBAC readily available to women, and should not be overlooked.

You and I are on the same page. The sentence previous to the one you quoted acknowledges that there are serious barriers to providing VBAC, but that they should be treated as obstacles to overcome, not as rationales for maintaining the status quo, which is what is happening now, including in the comments to this blog post.

Interestingly, ACOG’s “Code of Professional Ethics” supports the “obstacles to overcome” perspective:

“The respect for the right of individual patients to make their own choices about their health care (autonomy) is fundamental.”

“Conflicts of interest should be resolved in accordance with the best interests of the patient, respecting a woman’s autonomy to make health care decisions.” If not wanting to get sued isn’t a conflict of interest, I don’t know what is.

ACOG is an extremely powerful organization. If it chose to regard systemic barriers to VBAC in the light of obstacles, then it would and could do something about them, but as ACOG’s VP makes clear in the opening of my blog post, it does not. ACOG serves the interests of its constituency. Hale’s response tells us it is doing just that. If a groundswell of obstetricians were pressuring ACOG to make VBAC accessible in the name of patient autonomy, ACOG would take action–it certainly has had no problem defending elective first cesareans on that grounds. Even at the hospital level, as you point out, obstetricians and anesthesiologists could get together and arrange coverage for VBAC cases so as to meet ACOG recommendations. Where there’s a will, there’s a way. That so few clinicians and institutions have found a way and that ACOG itself opposes it tells me there is no will.

“obstetricians and anesthesiologists could get together and arrange coverage for VBAC cases so as to meet ACOG recommendations.”

Really? Please explain how it would be done. While you are at it, please explain what professional experience you have that even qualifies you to know whether it be done, what it would cost and what sacrifices clinicians would need to make in order to accomplish it.

Henci, you really need to decide what you value more: fanning the flames of resentment or finding a solution that will help women. You can’t do both.

As a provider who attends VBACs myself, I find your comment an embarrassment to our profession. It is unfortunate, if this was really the case, that professionals committed to the care of women would be this condescending to those whom they serve. I do not always agree with what my patients think or want, but I always treat them with respect. No eye-rolling here.

Henci could say “What a gorgeous day” and you would scream, “What makes you think you’re qualified to judge whether the day is gorgeous or whether it’s day or night?” You hate Henci. It goes beyond ideological differences and into the realm of how embarrassing.

Yes, Tuteur, it probably sucks for you to see that someone with your credentials wrote a book for consumers and it didn’t get nearly the sales that books written for consumers by a woman with a BA and years as a childbirth educator, doula, etc. did. I bet that stings.

And now you think she’s taken over your job of “fanning the flames of resentment” (See Comment 22) and you feel grumpy about that, too? You spend hours of every day trying to stir up resentment so that people will pay attention to you.

You can see that these behaviors lend themselves to people not taking you seriously in spite of your dazzling credentials (e.g., the Science Based Medicine crew and community).

Amy, you need to decide what you value more: acting like a jackass on the Internet or finding a solution that will help women. I have confidence that you can do both.

What I just DO NOT GET is the fact that OBs et al knowingly double the risk of uterine rupture with the use of synthetic oxytocin. If the system is so worried about preventable deaths and preventable lawsuits, how ’bout we ban induction/augmentation agents and “the clock” during VBAC?

In fact, if OBs et al REALLY cared about preventing The Preventables then we would see a stop-use for Cytotec.

You said VBAC activists use juvenile resentment tactics. I am not a VBAC activist. However, I am enjoying your juvenile resentment tactics, so you must be a VBAC activist. Nice to meet you.

Reading you whine about how only physicians are allowed to talk about physicians is so very embarrassing. I suspect that you are taken as seriously here as your were on Science Based Medicine.

You’re griping about Henci’s credentials because you want to be the authority. Aren’t there women who pay for your medical advice on the internet? They probably think you’re such an authority that you’re worth an introductory rate of $4.95!

Where is your evidence that OBs have been clamoring to attend VBACs? Or are you too wrapped up in trying to pin everything that’s bad in the world on Henci Goer. Global warming? That’s Henci. Inner-city crime? Henci’s fault. VBAC bans? Blame Henci and the fact that she’s not a doctor.

@Jennifer V.
>> Consumers will always be taken seriously. They’re where the money is.

Yeah Amy is right. Consumers are _not_ the insurers customers. The customers are the employers who buy employer based insurance. The employers are interested in getting enough coverage to keep their employees happy enough to not revolt for as little money as possible. Insurers look at consumers as the enemy – they’re the ones that spend their money!

>> In fact, if OBs et al REALLY cared about preventing The Preventables then we would see a stop-use for Cytotec.

Dead horse. miso is safe in most inductions. Not VBACs though.

>> Fogelson is really doing the same thing. He engages and listens but he has a similar goal. He speaks on behalf of all OB-GYNs and is trying to convince everyone that they’re really just a bunch of nice people.

My goal is dialogue for the most part. I do think we are getting unfairly maligned by the activist community. There are clearly some OBs that do shitty things and some that commit malpractice, but they are relatively rare. Complaining about those specific acts is justified. What I take issue with is the widespread slander against the whole field of obstetrics because of the actions of a few people. I have seen some midwives and homebirth attendants do some seriously ridiculous things like sew rectums to vaginas, fail to diagnose massive vaginal lacerations, and homebirth a breech leading to a fetal death, but I don’t continuously quote those anecdotes in an effort to slam homebirth or midwifery. Is it too much to expect the same respect in return?

One thing you are right about – there isn’t a groundswell of obstetricians trying to fight for VBAC rights. Most obstetricians think that we should do more VBACs, but it isn’t the first thing on our minds. There are lots of things that feel more important to many OBs, like:

1) doing a good job at work, delivering healthy babies, and not making a stupid mistake and hurting someone.
2) spending time with family
3) continuing to learn and stay current
4) getting research done (in academics)
5) paying the light bill
6) managing the office staff
7) working enough to pay ridiculous malpractice premiums
8) fighting like crazy to get insurers to pay us what we’re owed for the work we do
9) maybe finding some time to play with the kids / play a game of basketball / have a beer / see a movie.

So while doing VBACs is a great things most want to be able to do, the rank and file OB isn’t going crazy trying to change the field. Most are just trying to survive in changing healthcare system that makes it progressively more difficult to do what we love to do. There are so many things on a doctor’s mind _way_ more than VBAC. I think its an important issue, and I applaud you all for trying to bring it to the country’s attention. I also hope you all are successful in changing the many issues that decrease VBAC access in this country.

What I take issue with is the widespread slander against the whole field of obstetrics because of the actions of a few people. I have seen some midwives and homebirth attendants do some seriously ridiculous things like sew rectums to vaginas, fail to diagnose massive vaginal lacerations, and homebirth a breech leading to a fetal death, but I don’t continuously quote those anecdotes in an effort to slam homebirth or midwifery. Is it too much to expect the same respect in return?

But you’re pulling out those anecdotes now and they have nothing to do with this post. This is a discussion of obstetrics, not homebirth. You’re bringing your own “midwives are out to get me” business here on your own. You feel persecuted by 1 percent of birthing women in the U.S. and their midwives? Seriously?

You can talk to Tuteur, as she does pull similar anecdotes out as a response to discussions in obstetrics. She resents and slanders midwives and non-medical birth providers more than anyone.

Have you considered that it’s legitimate criticism and not slander?

You must know this isn’t just about a few people. Maybe in your circle, but open your eyes. It’s everywhere. Why is your cesarean rate so much lower than everyone else’s? You’re an anomaly and for some reason, you’re trying to convince women that you’re the norm.

I was going to apologize to you for being unnecessarily harsh but it looks like my assessment was right. Doctors are nice and we just would rather drink a beer and hang with our kids than advocate for our patients’ right to VBAC. Again, you’re speaking on behalf of all doctors. Why? It’s a great example of paternalism in medicine, which is actually my interest rather than birth-related issues.

@Nicholas FogelsonMy political activism is through my blog and social media activity, and I think so far its been pretty effective. My delayed cord clamping article had a fair bit of impact.
Ditto me, for the most part. [Your DCC article was my first impression of you, so we got off on the right foot, at least. :-)] However, I recently was part of a reactionary movement against MS making non-nurse midwives illegal, and since that was defeated, am now in a pro-active movement to make CPMs recognized and legal. [Current state law just defines midwife as a woman whose sole occupation is catching babies.] It’s getting me out of my comfort zone, which I think is a good thing. Also, it’s shown me that there still is power in “the voice of the people.” The response to the bill was unprecedented, and led to the bill not even making it out of committee. There were 5,000 phone calls on this issue, which may not seem like a lot, but apparently it was a lot more than normally happens.

I know this is getting off-topic, but think it is important to encourage people to understand that we still can get the attention of our elected officials, although it will take more time and energy than we are used to giving. And we need to turn our words into actions, if we want to see something done. It’s like Dr. Amy said in her grandstanding comments, saying that Henci’s article was grandstanding (a bit of the pot calling the kettle black, which is what drew me into the convo anyway) — if there is no solution, then it’s just words. I know that not everybody who sees a problem can see a solution, and sometimes it is helpful to have people gripe about a problem so that others can come up with a solution. I do that myself, from time to time. But once a solution is presented, it is then up to us to act on that, rather than just keep talking about it. Otherwise, it’s like people who say they want to lose weight, but keep sitting on the couch all day. Sorry for getting off-topic, but let’s start *doing* instead of just talking! Talking is fine and dandy — even necessary since it spreads the word so that more people can be motivated to action — but let’s combine it with action, since that is the only thing that can make change happen.

>> But you’re pulling out those anecdotes now and they have nothing to do with this post.

Just as an example. I was pointing out that I typically don’t pull out such anecdotes as I don’t believe they represent the norm. But why bother to defend there’s little point isn’t there?

I agree that there is potential to effect change in VBAC policies, but it will have to pass through the hands of the insurers first. As they have no financial stake in making that change, I suspect it would take some sort of federal regulation to change that.

>> If consumers were to take their business elsewhere, what would you bill for? You need patients to be able to bill insurance.

Ah.. and that is a problem. Honestly I don’t think insurance has much of a future. Its a failed experiment that will evolve into either a modified cash pay system or into true socialized medicine, either of which would be better that what we have now. Either system would improve choice to patients in general and restore some kind of balance to our system. I would welcome a system where the true cost of healthcare was transparently available to all and consumers could choose where they would like to spend their allotted healthcare dollars. Only then could the ‘consumer’ actually be the true customer of the healthcare system.

>> You must know this isn’t just about a few people. Maybe in your circle, but open your eyes. It’s everywhere. Why is your cesarean rate so much lower than everyone else’s? You’re an anomaly and for some reason, you’re trying to convince women that you’re the norm.

Many OBs have higher cesarean rates for sure, and that’s a shame. Its not slander to say that, its just fact. I don’t think my cesarean rate is the norm. Is is however at least partially a product of the environment I work in, an environment not shared by many practicing OBs. What I do think is the norm is my general regard for women’s autonomy, my care for my patients, and my belief in generally acceptable morals and ethics. What I find slanderous is claims that OBs in general do not hold to these basic ethics, as in my not-narrow experience this has not generally been true. A few exceptions yes, but rare.

>> I was going to apologize to you for being unnecessarily harsh but it looks like my assessment was right. Doctors are nice and we just would rather drink a beer and hang with our kids than advocate for our patients’ right to VBAC.

I don’t intend to speak on the behalf of all doctors, just my personal impression of most doctors. Nobody appointed me spokesperson, nor do I intend to be. My apologies if I appeared otherwise.

There are really quite a few articles out there, including lots of good review articles that bring them all together. Miso clearly speeds time to delivery in inductions with unfavorable cervices. It _is_ associated with increased meconium staining and uterine tachysystole, but has not been associated to date with adverse fetal outcomes. I don’t advocate it for every induction, but for many inductions it is quite useful. I generally don’t use it in pregnancies affected by growth restriction, oligohydramnios, or any condition that might portend poor placental perfusion, as these fetuses (I think) are more likely to have trouble in a rare uterine hyperstimulation event. Miso does occasionally cause this, but in a monitored setting there are many ways to deal with it.

Inductions in general will increase the rates of cesareans and abnormal heart rate tracings, as opposed to awaiting natural labor. There are typically done because it is believed there is some downside to continuing the pregnancy that is worth the risk of the induction. Miso is helpful induction agent in women with unfavorable cervices, and is a good option in many cases.

I don’t want to sidetrack comments here further onto discussing misoprostol, but I feel I have to point out that no randomized controlled trial or systematic review of RCTs will show the problem with misoprostol, which is that it causes the rare catastrophe. Even in the aggregate, the population will be too small to have a reasonable chance of detecting a statistically significant difference (meaning “unlikely to be due to chance”) between groups, a fact that the Hofmeyr review acknowledges. For a more extensive critique, please see my S&S blog post at http://www.scienceandsensibility.org/?p=467.

@Henci Goer
You’re right Henci – If miso truly has an association with adverse outcomes, it is a tiny association and would be very hard to find – which is why I can’t figure out why people keep trying to say miso is dangerous. Uterine ruptures occur without pit and without miso as well. I don’t believe theres even case control data to show that miso is associated with uterine rupture in an unscarred uterus.

There certainly have been a few case reports of uterine ruptures in unscarred uteri, and in some cases miso was used. The problem is that these are completely anecdotal and lack any denominator to actually allow us to show that miso causes this. I really disagree with the idea that there is data show show any association between miso and these outcomes. Henci’s post claims that miso is associated with these outcomes, but then also says that there isn’t any data to prove this. So basically it starts with the idea that miso causes these outcomes, admits there is not data to show this, and then says that that relationship is still there and we just can’t find it. To me that’s just speculation, not evidence.

In my experience, 25 mcg of miso every six hours does not lead to tetanic and strong uterine contractons, which would seem to be required to cause a uterine rupture. Ultimately a uterine rupture occurs when the path of least resistance for the baby is the uterine wall rather than the cervix. From a physics point of view this would take really strong contractions and a really tightly closed cervix.

I did see one uterine rupture at term after miso was used for four days in an attempt to deliver a term fetal demise, because nobody wanted to do a cesarean for a dead baby. Ultimately that was as poor choice. I suspect that most if not all uterine ruptures using miso were from similarly unusual circumstances, though I admit this is speculative.

Chukwuma made a good point about consent best being defined as a description of what we can expect to happen, and what problems we could reasonably be expected to have. I don’t think that uterine rupture is a complication we can be reasonably expected to have in any case, miso or not.